OLD TOWN SPIRALS | Client Intake Form

OLD TOWN SPIRALS | Client Intake Form

Please complete this form to help us understand your health history, movement background, and goals for your sessions.
Client Information
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Emergency Contact Name

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Current Injuries or Physical Limitations
Do you currently have any injuries or physical limitations?
If yes, please describe your current injuries or limitations:
Movement Background
Have you practiced GYROTONIC® or GYROKINESIS® before?
Please check any other movement practices you participate in:

Other
If you selected 'Other', please specify:
Goals for Your Sessions
What are your goals for your sessions? (Select all that apply)

Other
If you selected 'Other', please specify:
Acknowledgment
I understand that it is my responsibility to inform my instructor of any changes in my health status, medical condition, or physical limitations before participating in any GYROTONIC® & GYROKINESIS® session.
Signature
Date

MonthDayYear
Date
Should be Empty: